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Introduction: Both suicide and self‐harm are disproportionately common in autistic people. Sex differences in risk of self‐harm and suicide are observed in the general population, but findings are mixed for autistic people. Self‐cutting may be a particularly risky self‐harm behaviour for suicide in autistic people. We aimed to explore sex differences and differences in method of self‐harm in the association between self‐harm and suicide in autistic and non‐autistic adolescents and young adults. Methods: We used a total population register of 2.8 million Swedish residents. Participants were followed from age 12 until December 2021 for medical treatment because of self‐harm, and death from suicide. We used Cox proportional hazard regression models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of death from suicide following self‐harm, and Relative Excessive Risk due to Interaction (RERI) to explore the interaction between self‐harm and autism in females and males. Results: We identified 85,143 autistic individuals (31,288 female; 53,855 male) and 2,628,382 non‐autistic individuals (1,286,481 female; 1,341,901 male) aged 12–37 years. Incidence of suicide following self‐harm was higher in autistic males (incidence per 100,000 risk‐years = 169.0 [95% CI 135.1, 211.3]) than females (125.4 [99.4, 158.3]). The relative risk was higher for autistic females (HR 26.1 [95% CI 20.2, 33.7]) than autistic males (12.5 [9.9, 15.8]). An additive effect of both autism and self‐harm was observed in both females (RERI = 9.8) and males (2.0). Autistic individuals who self‐harmed through cutting were at greatest risk of death from suicide (HR 25.1 [17.9, 35.2]), compared to other methods. Conclusion: Autistic males and females are at increased risk of death from suicide following severe self‐harm, particularly self‐cutting. [ABSTRACT FROM AUTHOR]

Objectives: To explore how former patients in dialectical behaviour therapy for adolescents (DBT‐A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful. Design: From a larger sample of 75 former DBT‐A patients 19 were selected for a qualitative semi‐structured interview study. Methods: Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT‐A due to self‐harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented. Results: Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life‐changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings. Conclusion: A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT‐A as suitable and the need for sufficient treatment dose was emphasized. [ABSTRACT FROM AUTHOR]

Objective: Self‐harm among young autistic individuals is a clinical challenge, and the risk of premature death by suicide is strongly increased in this group. Using the advantage of total‐population and family‐based data, we investigated whether autism per se is a risk factor for self‐harm independently of psychiatric comorbidities and how it differs from self‐harm in non‐autistic individuals. Methods: We used The Stockholm Youth Cohort, a total‐population register study, including all residents in Stockholm County aged 0–17 years between 2001 and 2011.Study participants were followed from age 10 to 27 for hospital admissions because of self‐harm. We used modified Poisson regression to calculate relative risks (RR) using robust standard error to derive 95% confidence intervals (CI). Results: In all, 410,732 individuals were included in the cohort (9,070 with a diagnosis of autism). Autistic individuals had a fivefold increased adjusted relative risk of self‐harm (RR 5.0 [95% CI 4.4–5.6]). The risk increase was more pronounced for autism without intellectual disability and particularly high for self‐cutting 10.2 [7.1–14.7] and more violent methods 8.9 [5.2–15.4]. The association between autism and self‐harm was independent of, but clearly exacerbated by comorbid psychiatric conditions. It was of similar magnitude as risks linked to these conditions per se, and not explained by shared familial factors. Conclusion: Self‐harm severe enough to present to medical services is as common in autistic youth as in those with depression or ADHD. Potentially more lethal methods are more likely to be used of autistic self‐harmers. [ABSTRACT FROM AUTHOR]

Objective: Childhood attention‐deficit /hyperactivity disorder (ADHD) is known to be associated with adult Borderline Personality Disorder (BPD). We investigated if any of the subdimensions of childhood ADHD, that is, impulsivity, inattention, or hyperactivity was more prominent in this association. Methods: In a nation‐wide cohort (N = 13,330), we utilized parent reported symptoms of childhood ADHD and clinically ascertained adult BPD diagnoses. The summed total scores of ADHD symptoms and its three subdimensions were used and standardized for effect size comparison. Associations were analyzed using Cox regression with sex and birth‐year adjustments. Secondary outcomes were BPD‐associated traits (i.e., self‐harm and substance use) analyzed using logistic‐ and linear regression respectively. Results: ADHD symptom severity was positively associated with BPD with a hazard ratio (HR) of 1.47 (95% confidence interval [CI]: 1.22–1.79) per standard deviation increase in total ADHD symptoms. Impulsivity was the most prominent subdimension with the only statistically significant association when analyzed in a model mutually adjusted for all ADHD subdimensions—HR for inattention: 1.15 (95% CI: 0.85–1.55), hyperactivity: 0.94 (95% CI: 0.69–1.26), impulsivity: 1.46 (95% CI: 1.12–1.91). In secondary analyses, weak positive associations were seen between total ADHD symptom score and self‐harm and substance use. In analyses by subdimensions of ADHD, associations were weak and most prominent for inattention in the model with self‐harm. Conclusion: Childhood ADHD symptoms were associated with subsequent development of BPD diagnosis and appeared to be driven primarily by impulsivity. Our findings are important for understanding the association between childhood symptoms of ADHD and subsequent BPD. [ABSTRACT FROM AUTHOR]

Background: More knowledge about risks of clinical outcomes associated with nonsuicidal self‐injury (NSSI) and suicide attempts (SAs) is needed to inform risk assessment and intervention. Methods: Longitudinal cohort study based on 1,855 youths was clinically assessed for NSSI and SA, and followed up (from December, 2011 to December 2013) for the outcomes; diagnosed self‐injury, alcohol/substance use disorder, and psychiatric inpatient care data derived from Swedish registers. Hazard ratios (HRs) and 95% confidence intervals (CIs) of the outcomes were estimated with Cox regressions, and additionally adjusted for the potential effect of sex and the number of clinical assessments. NSSI and SA were treated as time‐varying covariates. Results: Youths with NSSI had elevated risks of all outcomes, compared with youths without NSSI or SA; the HR was 2.3, 95% confidence interval [1.6, 3.4] for self‐injury, 1.4 [0.9, 2.1] for alcohol/substance use disorder, and 1.3 [1.0, 1.7] for psychiatric inpatient care. Youths with SA displayed higher risks for the outcomes than the NSSI group; the HR was 5.5 [2.4, 12.6] for self‐injury, 2.0 [0.9, 4.4] for alcohol/substance use disorder, and 2.6 [1.5, 4.5] for psychiatric inpatient care. Youths with both NSSI and SA showed similar risks as youths with SA; HR 4.1 [2.0, 8.3] for self‐injury, 2.0 [1.1, 4.1] for alcohol/substance use disorder, but a higher risk of psychiatric inpatient care; HR 5.0 [3.1, 7.9]. All results remained virtually unchanged in the adjusted analyses. Conclusions: Youths with NSSI and/or SA had higher risks for subsequent adverse clinical outcomes. These excess risks were more pronounced among youths with SA and youths with both NSSI and SA, and the risk for psychiatric inpatient care was particularly high in youths with both NSSI and SA. Our findings suggest that early interventions for youths with NSSI or SA should not exclusively focus on suicide prevention, but also consider the risk of subsequent alcohol/substance use disorder. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether patients with clozapine treatment are at an increased risk of a more severe COVID‐19 infection as compared with patients on other antipsychotic drugs. Methods: In this register‐based cohort study, all residents (age 18 or older) in the Stockholm Region with a psychotic disorder diagnosis and antipsychotic treatment were included (N = 8 233) and followed from 1 March 2020 to 14 January 2021. The exposure was defined as clozapine treatment and the outcome measures (indicating a more severe COVID‐19 infection) were: inpatient care, care within intensive care unit or death due to COVID‐19 infection. Differences in outcome rates between exposed (n = 966) and unexposed (other antipsychotics; n = 7 267) were examined using Cox proportional hazards models and expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results: No statistically significant differences in outcome rates were found between the two groups of patients after adjusting for age, sex and residence in retirement homes. The adjusted HR for the exposed compared to the unexposed was 0.96 (95% CI: 0.54, 1.70) for inpatient care; 1.69 (0.48, 5.93) for care in intensive care unit (ICU); and 0.86 (0.26, 2.80) for death. Regarding inpatient care, additional adjusting for country of birth, living in socioeconomically vulnerable areas, number of care visits during the previous year, and comorbid medical illnesses did not alter the results. Conclusions: Our results may add support to the present guidelines, recommending sustained clozapine treatment during the current COVID‐19 pandemic with careful monitoring and readiness to alter drug doses as needed. [ABSTRACT FROM AUTHOR]

Background: Self‐harm is common and there is a need for studies that investigate the relevance of this behavior in clinical samples to inform risk assessment and treatment. The objectives in the current studies were to compare clinical and psychosocial correlates and subsequent adverse outcomes in youth who present to child and adolescent mental health services (CAMHS) with self‐harm only (SH), self‐harm with suicidality (SH+SU), with those without any indication of SH or SH+SU. Methods: We conducted a case–control study and a longitudinal cohort study using data from a regional clinical care register, and Swedish national registers. The case–control study included all patients (5–17 years) between 2011 and 2015 (N = 25,161). SH and SH+SU cases were compared with controls (patients without SH) regarding a range of correlates. The longitudinal study included former CAMHS patients (N = 6,120) who were followed for a median time of 2.8 years after termination of CAMHS contact regarding outcomes such as clinical care consumption, social welfare recipiency, and crime conviction. Results: In the case–control study, both the SH and SH+SU groups received more clinical care, had lower global functioning, and higher odds of having mental disorders compared to controls. In most comparisons, the SH+SU group had more problems than the SH group. In the longitudinal study, the same pattern emerged for most outcomes; for example, the adjusted hazard ratio for recurrent care due to self‐harm was 23.1 (95% confidence interval [CI], 17.0–31.4) in the SH+SU group compared to 3.9 (95% CI, 2.3–6.7) in the SH group. Conclusions: Adolescent patients presenting with self‐harm have higher risks for adverse outcomes than patients without self‐harm. Suicidality in addition to self‐harm is associated with more severe outcomes, importantly recurrent episodes of care for self‐harm. [ABSTRACT FROM AUTHOR]